Gastrointestinal bleeding in patients receiving long-term anticoagulant therapy

  • C.Mel Wilcox
    Department of Medicine and Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, USA
    Search for articles by this author
  • Christopher D. Truss
    Requests for reprints should be addressed to Dr. Christopher D. Truss, Division of Gastroenterology, University of Alabama at Birmingham, University Station, Birmingham, Alabama 35294.
    Department of Medicine and Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, USA
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.


      When gastrointestinal (GI) bleeding occurs in patients receiving anticoagulation, an underlying pathologic lesion is usually suspected and a thorough diagnostic evaluation is undertaken. Over a 15-year period, 50 patients were identified as having GI bleeding while receiving warfarin. Approximately half of all bleeding episodes occurred from the upper GI tract, with a lesion identified 81 percent of the time, usually peptic ulcer disease. Lower GI bleeding occurred in one-third of bleeding episodes, with a diagnosis made in only 52 percent. Only three neoplasms were found and all were diagnosed by barium studies. No diagnosis was established in 47 percent of all bleeding episodes despite appropriate evaluation; in these patients, a mean follow-up of 39.6 months disclosed no premalignant or malignant lesions. Mortality associated with bleeding was less than 2 percent. These data suggest that a diagnosis is usually established in patients receiving anticoagulation who experience upper GI bleeding, whereas the cause of lower GI bleeding may remain occult even after a thorough evaluation; however, the absence of a definitive diagnosis carries a good prognosis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stern S
        • Dreskin OH
        Bleeding from occult disease during anticoagulant therapy.
        Angiology. 1957; 8: 337-340
        • Hemley SD
        • Arida EJ
        • Schwartz MJ
        Occult lesions discovered during anticoagulant therapy.
        JAMA. 1961; 177: 153-155
        • Carey RJ
        Warfarin-induced rectal bleeding as clue to colon cancer.
        Lancet. 1984; I (letter): 505-506
        • Parsa F
        • Wilson SE
        Bleeding diverticulosis in patients on oral anticoagulants.
        Am J Surg. 1974; 127: 708-710
        • Roos J
        • Van Joost HE
        The cause of bleeding during anticoagulant treatment.
        Acta Med Scand. 1965; 178: 129-131
        • Second Report of the Sixty Plus Reinfarction Study Research Group
        Risks of long-term oral anticoagulant therapy in elderly patients after myocardial infarction.
        Lancet. 1982; I: 64-68
        • Coon WW
        • Willis PW
        Hemorrhagic complications of anticoagulant therapy.
        Arch Intern Med. 1974; 133: 386-392
        • Zweifler AJ
        Relation of prothrombin concentration to bleeding during oral anticoagulant therapy.
        N Engl J Med. 1962; 267: 283-285
        • Stevenson GW
        • Cox RR
        • Roberts CJC
        Prospective comparison of double-contrast barium meal examination and fiberopticf endoscopy in acute upper gastrointestinal hemorrhage.
        Br Med J. 1976; 2: 723-724
        • Bronfield MW
        • McIllmurray MB
        • Ferguson R
        • Atkinson M
        • Langman MJS
        A prospective randomized study of endoscopy and radiology in acute upper-gastrointestinal-tract bleeding.
        Lancet. 1977; I: 1167-1169
        • Thoeni RF
        • Cello JP
        A critical look at the accuracy of endoscopy and double-contrast radiography of the upper gastrointestinal (UGI) tract in patients with substantial UGI hemorrhage.
        Radiology. 1980; 135: 305-308
        • Gilbert DA
        • Silverstein FE
        • Tedesco FJ
        The National ASGE Surgey on Upper Gastrointestinal Bleeding. III. Endoscopy in upper gastrointestinal bleeding.
        Gastrointest Endosc. 1981; 27: 94-102
        • Kelvin FM
        • Gardiner R
        • Vas W
        • et al.
        Colorectal carcinoma missed on double-contrast barium enema study: a problem in perception.
        AJR. 1981; 137: 307-313
        • Gelfand DW
        • Ott OJ
        Single- versus double-contrast gastrointestinal studies: critical analysis of reported statistics.
        AJR. 1981; 137: 523-528
        • Kelvin FM
        • Dodson TA
        • Rice RP
        • et al.
        Double-contrast barium enema in Crohn's disease and ulcerative colitis.
        AJR. 1978; 131: 207-213
        • Thoeni RF
        • Menuck L
        Comparison of barium enema and colonoscopy in the detection of small colonic polyps.
        Radiology. 1977; 124: 631-635
        • Teague RH
        • Manning AP
        • Thornton JR
        • Salmon PR
        • Read AE
        Colonoscopy for investigation of unexplained rectal bleeding.
        Lancet. 1978; II: 1350-1352
        • Tedesco FJ
        • Wayne JD
        • Raskin JB
        • Morris SJ
        • Greenwald RA
        Colonoscopic evaluation of rectal bleeding.
        Ann Intern Med. 1978; 89: 907-909
        • Miller RE
        Detection of colon carcinoma and the barium enema.
        JAMA. 1974; 230: 1195-1198
        • Tedesco FJ
        • Pickens CA
        • Griffin Jr, JW
        • Sivak Jr., MV
        • Sullivan Jr, BH
        Role of colonoscopy in patients with unexplained melena: analysis of 53 patients.
        Gastrointest Endosc. 1981; 27: 221-223